For some reason, I seem to be the ketamine queen in our er. The docs have started to use it on kids for extensive lacs or reductions when the kids are really (really, really) uncooperative or we are just not able to get them to be still for the tx. First time, it scared the holy *** out of me!. I looked it up before giving it, but still........... this fat little two year old went from screaming at the top of his lungs, and flailing all over the place, to this tranquil little (well, fat) kid laying limply on the stretcher with his eyes jerking back and forth. looked like he was watching tennis or something. can you say nystagmus (sp?). I got the doc because the mom was freaking out (causing me to try to look like I was NOT freaking out). He takes one look at the kid and says, "oh...he's just hallucinating" Our tech (college kid) happened to stroll by and announced to me that the kid was "in the K-Hole" (apparently the lingo when you do the drug illegaly, what do I know?:chuckle )
anyway, now I have administered it to three or four kids, and to my knowledge, none of the other nurses in the department have had this "wonderful learning opportunity" the kids come out of it fine, and I've had no problem. I have been following our iv conscious sedation protocol, but am wondering if I should be doing anything else? the protocol was written for adults, and all the little ketamine people are kids. I don't do peds! (I do that at home in my off time). anybody else have protocols specifically for ketamine or peds ivcs?
I worked in the OR for 13 yr, and now in the ED for 14 yrs. Without a doubt, ketamine and propofol are wonderful drugs. In my opinoin they shouldn't be administered in the ED by RN's for exactly the reasons that Veetach mentioned.
Let's have these same MD's who are ordering it, take responsibility and administer it themselves. Let's see how often they want to do it then? I find that they are unwilling to do themselves what they want us to do.
The ED setting is probably the LAST place this should be done. At least in an endo lab/procedure room no one gets distracted by the drunks and the psychs not to mention arrests or trauma that roll in the door...ALWAYS at the worst possible time!
But how about this scenrio...
We have a lot of frequent flyers/drug seekers...of course.
One of our migraines came in and the doc ordered 200 of meperedine IV and 200 of diphenhydramine IV!!??!! Can we say respiratory depression here?!
The nurses refused...smart ain't we??!! The doc was furious! But...would he do it himself!?? Not a chance.
in the ER I have only ever given propofol to an already tubed patient...
a few mos ago i was a die-hard ED nurse who believed that we could handle/do anything...but after only a month or so in school...knowing what i know now about these meds (which isn't even a full knowledge base yet) - please trust me when i say they should not be given by RN's in the ED....the interactions, the actions, and the adverse reactions are extensive....and although i pride myself on being familiar w/ the med prior to utilizing it.... the little drug books we use don't tell you alot that you should really know
We had Ketamine pulled from our Pyxis several months ago because #1) it was not being used and #2) there were concerns about its safety because of its irreversibility and long half-life and lack of staff knowledge about the drug. I have seen it used twice by DOCTORS for lac and ortho moderate sedation in kids. Doctors can still order it from pharmacy, if they want it. I don't like the drug, personally.
Our docs like Diprivan for moderate sedation proceedures because of its short half-life. CYA nurses! Make the MD administer this drug on non-intubated patients and document that the doctor administered it! In general, I like this drug for moderate sedation for otherwise healthy adults. I have seen a few patients require ambu for several breaths and we had one elderly patient who retained CO2 and needed Bipap after she did not wake after 1 hour + (new grad RN and MD slow on the draw for that one). Hypotension usually reverses upon withdrawal of drug.
I love Dip for intubated patients, but watch out with CHF-ers. That SBP of 200 will be in the bargain basement once the 80 of lasix and nitro paste kick in and you finally have the Dip titrated to keep the patient from bucking .
confusion...........this article states half-life much less than previous post reply of 5 hours. good article, though.
The first time I gave ketamine, I put it in my pocket, having read that sometimes a 2nd dose is necessary. I then took it home with me at the end of my shift! (Have 6 pockets, will travel). I was not sure what to do, didn't have to work for 4 days, didn't want to make a special trip to return. Ended up returning it when I went in. Good grief.
peds with lacs that really need to be still, reducing dislocations and all
Ketamine really is good on the pedis
all conc.sedations are on monitor, pulse ox, O2 etc and are always one on ones untill stable. regardless of whats happening elswhere.
we also use dip for adult reductions works great
Had a big bodybuilder come in with dislocated shoulder versed and fentanyl wouldnt relax him enough for reduction. A ittle dip and it popped back in without diff.
The key to these meds is knowing them using them appropiately with all the proper safeguards including ER Phys at bedside the entire time
Another good med is Brevitol works wonderously well
Conc sedation in our ER requires an Informed Consent signed by the pt.
The elimination half-life of ketamine is close to 5 hours. It is a LONG LASTING drug.. If you don't believe me, do a Google search (ketamine Half-life).
Please tell me how you can administer a medication that you know nothing about???
Yoga CRNA
hmmmmm....rapid absorption and half life of 5-7 minutes????? Maybe I am not as stupid as yoga thinks I am??? BTW where has the yoga disappeared to?
mmmmmm.... you all make a big mistake by egging on those who are much more educated in the matter of medicine's as you...
actually ketamine has a short duration of action...you are right about that veetach...however... ketamine is highly lipid soluable and has a large Vd (volume of distribution) 3L/kg....
what that means is that ketamine quickly moves out of the central compartment of its target cells and into the periph. compartment where it is readily stored in fat... the elimination half-time is 2-3 hours (this number ultimately depends on which text you refer to)
so...yoga was of course right...because what goes into the periphery...must come out to be metabolized and excreted..that means the effects can come back and bite you in the a$$.
i hope you are are comfortable handling a laryngospasm caused by ketamine induced secretions...your license.
mmmmmm.... you all make a big mistake by egging on those who are much more educated in the matter of medicine's as you...
actually ketamine has a short duration of action...you are right about that veetach...however... ketamine is highly lipid soluable and has a large Vd (volume of distribution) 3L/kg....
what that means is that ketamine quickly moves out of the central compartment of its target cells and into the periph. compartment where it is readily stored in fat... the elimination half-time is 2-3 hours (this number ultimately depends on which text you refer to)
so...yoga was of course right...because what goes into the periphery...must come out to be metabolized and excreted..that means the effects can come back and bite you in the a$$.
i hope you are are comfortable handling a laryngospasm caused by ketamine induced secretions...your license.
we sometimes give Ketamine to Pediatric patients for conscious sedation, usually to repair lacs. A small amount, they dont stay under long and they are easily aroused when the procedure is done. We also give Atropine to control Ketamine induced secretions... BTW I wasnt egging on, Yoga was the original flame thrower.
I am not throwing flames, just speaking the truth. Personally, I don't care what you do in your ER, but I have a right to express my opinion, which is based on over 44 years experience as a CRNA, an author of two books, an editor of an anesthesia journal and by the way, I have a law degree. I took pharmacology at a prominent medical school and have administered ketamine since it came on the market. Once at a major hospital, I was called into an operating room to assist another CRNA who had given ketamine to a patient who was NPO and was having elective surgery. The patient vomited and aspirated, had to be intubated in the prone position and almost arrested. I have a lot of respect for ketamine, even in small, "sub-clinical doses".
Quality patient care is not a bunch of words, but a way of practice for me. I don't attempt to do things or give meds until I have studied and researched the literature. Life is too precious.
I am not throwing flames, just speaking the truth. Personally, I don't care what you do in your ER, but I have a right to express my opinion, which is based on over 44 years experience as a CRNA, an author of two books, an editor of an anesthesia journal and by the way, I have a law degree. I took pharmacology at a prominent medical school and have administered ketamine since it came on the market. Once at a major hospital, I was called into an operating room to assist another CRNA who had given ketamine to a patient who was NPO and was having elective surgery. The patient vomited and aspirated, had to be intubated in the prone position and almost arrested. I have a lot of respect for ketamine, even in small, "sub-clinical doses".
Quality patient care is not a bunch of words, but a way of practice for me. I don't attempt to do things or give meds until I have studied and researched the literature. Life is too precious.
YogaCRNA
You have been a CRNA since 1960?? Yah, Ok, whatever... personally, your credentials do not impress me, it is obvious that time is marching on and hospitals are giving Ketamine in the ER regardless of what you say. It is a moot point.
If you are inferring by your condescending rhetoric, that I do not value patient care, then you are nothing short of pompous. You do not know me, nor have you ever worked along side me. Again, your delivery of text is set forth in a flaming manner.
Have you ever practiced in a setting outside of the operating room? Oh, nevermind I really dont care.
Being an attorney doesnt impress me either. I am from a family with many professionals, including physicians and attornies. Big deal.
Our tech (college kid) happened to stroll by and announced to me that the kid was "in the K-Hole" (apparently the lingo when you do the drug illegaly, what do I know?:chuckle )
Terryw
12 Posts
I worked in the OR for 13 yr, and now in the ED for 14 yrs. Without a doubt, ketamine and propofol are wonderful drugs. In my opinoin they shouldn't be administered in the ED by RN's for exactly the reasons that Veetach mentioned.
Let's have these same MD's who are ordering it, take responsibility and administer it themselves. Let's see how often they want to do it then? I find that they are unwilling to do themselves what they want us to do.